Health Care Gains Recognition as Bridge to Stability

By John J. Kruzel
American Forces Press Service

Nov. 23, 2009 - A theory gaining momentum among counterinsurgency and military medical experts is that the health of a nation's people affects the health of a nation. While no formal study has confirmed a causal connection, evidence culled from U.S. commanders as well as American allies and adversaries, suggests a correlation between health and stability. With the Defense Department's growing emphasis on stability operations, a better understanding of this relationship could help inform U.S. foreign policy.

"It is increasingly recognized that health is a critical bridge to peace and stability around the globe," said Navy Cdr. David Tarantino, M.D., in a presentation on Defense Department stability operations policy. "Health is perhaps the quintessential service among all essential services."

Early recognition of health as a stabilizing factor appears in the Geneva Convention of 1949, which requires an occupying force to contribute to its host nation's health-care infrastructure. Over the following decades, world superpowers including the United States and China and paramilitary groups like the Irish Republican Army and even al Qaida have recognized the strategic role health plays, officials said.

In modern-day counterinsurgency conflicts, where gaining support of the people is the prime objective, one of the crucial aspects is to provide the population essential services that improve quality of life, said retired Army Col. Pete Mansoor, the founding director of the U.S. Army/Marine Corps Counterinsurgency Center at Fort Leavenworth, Kan.

Mansoor, a professor at the Ohio State University, served as the executive officer to Army Gen. David Petraeus, then commander of Multinational Forces Iraq. He assisted in the strategic planning for the U.S. war effort in Iraq, including the troop surge that is largely credited with increasing Iraq's stability.

"Medical care is among the most sought after resource in this regard, as people worldwide appreciate good health over most other aspects of the human condition," he said in an e-mail today. "In counterinsurgency operations, doctors and other health-care professionals can be as important as soldiers."

Dr. Lynn Lawry, the senior health stability and humanitarian assistance specialist in the Defense Department's International Health Division, characterized health care as a "moderator" of stability.

"If you think about it, health is a basic need like food, shelter, clean water, health-care access --being able to get your kids help," she said in an interview last month. "What the anecdotal evidence points to is that health is really stability."

Lawry described two phenomena that suggest a link: the correlation between infant mortality rates and stability, and the incidence of mortar attacks on an area's health-care infrastructure.

As the stability of an area decreases, Lynn said, there is a dramatic increase in infant mortality, which is defined as the number of deaths of children one year or younger per 1,000 live births. Conversely, improved stability is met with a drop in infant mortality.

"That's a disproportionate marker," Lawry said of infant death rates. "It goes way up, as opposed to some of the other markers. So you can look at infant mortality, and that is directly related to having health-care services as a marker for stability."

Anecdotal evidence from the battlefield also suggests that health care can create stability. Military units in the field that are being shelled with artillery fire have found that medical care has proven to be a defensive measure in some instances, Lawry said.

"They go out into the community and set up some type of medical programming in the surrounding area," she said, noting that such facilities often meets the needs of communities lacking infrastructure to treat women and immunize children. "Then, all of a sudden, the mortars stop."

Evidence from conflict zones like the Gaza Strip, where Hamas' first social priority has been to provide health care, followed by education, and data from the Kosovo War in the late 1990s also suggest a connection, Lawry said.

"If you look at Gaza where there was a huge amount of uprisings and problems, they went in and put in a health clinic basically on every corner and stability ensued," she said. "The same thing happened in the opposite way in Albania where there was lots of health-care services. As health care started dwindling, so did stability."

Navy Lt. Cdr. William J. Hughes, MSC, the program director for contingency planning at the International Health Division, said insurgent groups have long recognized the value of health care in winning popular support.

"Michael Collins of the IRA wrote in his doctrine that if you break down the state and you want to view yourself -- the insurgency -- as the legitimate form of government, then health care is [critical]," he said in an interview last week.

Hughes noted that after the earthquake in Kashmir, the disputed region between India and Pakistan, the first medical unit to respond was one with direct links to al Qaida. "Now there's an adversary of ours who's learned what health can do to an environment," he added.

Hughes noted that countries like Venezuela and Cuba send their doctors around the globe to perform health care, and that China recently converted one of its ships into a floating hospital.

The move by China is similar to efforts by two American vessels, the USNS Mercy and USS Comfort, which travel to impoverished or disaster-stricken countries to provide medical care.

Such "soft power" operations, which emphasize non-military government efforts, have gained visibility with the Defense Department this year, reaffirming a policy directive that puts stability operations on equal footing with major combat operations.

"This directive said that stability operations were on par with major combat operations," Hughes said of directive 3000.05. "Now that's groundbreaking. That's transformational because now when you do that, you say you have to train, equip and fund people to do these kinds of operations."

Hughes said critics expressed concern that the directive, created in 2005, would place the military at the front of America's image abroad, echoing concern that Defense Secretary Robert M. Gates has voiced about U.S. foreign policy's "creeping militarization." But Hughes said medical workers in uniform are unique in that they often are viewed as "neutral players," with an interest primarily in providing care.

"We have this Hippocratic Oath. It's in our blood to want to care and do good things," he said. "You can provide [health care] and you're not necessarily going to be viewed as an agent of your nation's policies."

Further, Hughes emphasized that the department's International Health Division, which aids the combatant commands in coordinating and carrying out health aspects of the department's stability operations, is concerned primarily with helping partner nations build their own capacity to provide health and maintain stability.

"[Sometimes] we work with the host nation so that we can work ourselves out of a job," he said of the division's mission to train its allied counterparts. "That's what we want to do with stability ops -- we don't want to stay."

Lawry, Hughes' colleague at the division, underscored that no formal evidence-based assessment has been conducted that establishes the link between health and stability.

"But you can say, anecdotally, that's what it looks like," she said. "It deserves a study."